To STEMI or not to STEMI, that is the question...

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EMSrush

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Got an interesting call today, and wanted some feedback from you guys.

We received a Priority 2 call to an urgent care center for a 40 y/o male, possible STEMI. (Yes, we asked dispatch to repeat our response priority, too.) U/A, Pt was sitting up in bed, no visible distress, smile on his face. In condensed form, the conversation between me and the RN went something like this:

RN: This is a 40 y/o male who was having chest pain during dialysis this morning. EMS brought him in here. He's not having any chest pain right now, we gave him ASA and Nitro. The doctor noticed some changes when he compared an old EKG to the one we did today. [RN holds up a rhythm strip briefly] He has had three MIs in the past. Now, we're sending him over to ABC hospital to rule out a STEMI.
Me: Was there any elevation?
RN: I don't know. I don't think so.
Me: How are his vitals?
RN: BP in the 170's, Pulse in the 60's.
Me: Do you have his 12 Lead?
RN: Yeah, somewhere.
Me: Can I take a look please?
RN: Here.

The hospital's 12 Lead showed elevation in V3, V4, V5. It was about an hour old. I put him on my monitor (BP 175/102, Pulse 65, BPM 16, SpO2 100), and got this:

2011-09-29203452.jpg


Next, I did a 12 lead and got this:

2011-09-29203715.jpg


To make a long story short, we arrived at the ED and my 12 Lead was shown to the attending. He shrugged and said, "Not a STEMI" and walked away. I was perplexed; there seems to be clear elevation to me. Had I got this Pt as an emergency call, I would have called in a STEMI to the hospital. Can anyone explain to me why the attending said what he did? I realize that there's a few things going on in the 12 lead, but I don't see why the elevation was not significant. Please tell me what you see, and what you don't see.

Anyone care to take a crack at it? I realize the pics aren't the best, but give it a try anyway. :)
 
I wouldn't have called a STEMI, but would have noted the specific findings.


Only things that can be considered elevation are in III and V3 (and III is pushing it), but as you know, the typical rule is "contiguous leads", of which they are not. I and aVL have what can be said as depression (or at the very least, inversion), and V2 has T-wave inversion.





Did they not do cardiac enzymes or a 15-lead?
 
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I would have asked for an enzyme test if they could have, and would have done a 15 myself.



Myself, if I get a patient complaining of symptoms that can be construed as a possible MI, but a 12-lead doesn't show anything, I do a 15.
 
One can not call STEMI based on the limb lead print out because of the frequency response... so that elevation in II, III and AVF are not reliable indicators by any means, and never should be. The difference in the monitoring frequency will cause artifact like that. That is only a monitoring print out and view on the screen.

The 12 lead print out kinda remotely shows ST elevation in V3.... but no where else. That could be caused by a wayward V3 lead. You need changes in 2 more consecutive leads on the 12 lead print out.

The pt sounds stable and in no distress, if was having a STEMI.... you will know it.

Good learning stuff!!!
 
Linuss said:
I would have asked for an enzyme test if they could have, and would have done a 15 myself.



Myself, if I get a patient complaining of symptoms that can be construed as a possible MI, but a 12-lead doesn't show anything, I do a 15.
Click to expand...

I agree with you about the 15 lead...
Do you feel that V4 has elevation at all?

In my system, we are supposed to call in a STEMI if .5mm or more of elevation, OR if machine interprets acute STEMI.
 
MasterIntubator said:
The pt sounds stable and in no distress, if was having a STEMI.... you will know it.
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Not necessarily. I've had people complaining of nothing more than "not feeling right", and I've had others make you think all their limbs were torn off in a farming combine.
 
This is not a STEMI,

The leads that have elevation are not contiguos and it has LVH. LVH can mimic elevation, I would have treated him the way you did. But no call on the STEMI.

And remember, those lifepaks are about 60-something percent accurate. Don't look at its interpretation.

On another note, if you are ever on the bubble as to wether this is a STEMI or not. Look for reciprical changes. Now let me ask you, did this one have any?
 
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I would not have called that a STEMI either. As MasterIntubator said, monitoring mode can show elevation frequently but on 12-lead no elevation.

I only see elevation in V3.

I'm curious as to why you made this statement, "Had I got this Pt as an emergency call, I would have called in a STEMI to the hospital". Why does how you received the call determine when you call a STEMI? A patient is a patient. Just curious.
 
MasterIntubator said:
The pt sounds stable and in no distress, if was having a STEMI.... you will know it.

Good learning stuff!!!
Click to expand...

I disagree, Atypical S/S resulting in STEMI diagnosis are very common in Women, Diabetics, the Elderly. That is why we do 12-Leads on so many different Chief Complaints.
 
18G said:
I'm curious as to why you made this statement, "Had I got this Pt as an emergency call, I would have called in a STEMI to the hospital". Why does how you received the call determine when you call a STEMI? A patient is a patient. Just curious.
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Fair question. I'm still a new paramedic, and I was not lead on this call. I was a bit surprised at the feet dragging and "We're still working on his paperwork" delays that I encountered. I didn't feel like a had a tremendous amount of control over the call due to report already having been called in to the receiving ED, and not being the Pt's caregiver. I'm still trying to develop a balance between trusting my (limited but expanding) knowledge base, and the experience of others.

I ended this call feeling kind of "blah". I'm not even sure why, but I'm suspecting it has to do with my lack of participation and some confusion/uncertainty on my part. That's why I'm here.
 
Guess I should have worded it... "You will most likely know it", leaving it open for those uncommon ones.... as I too have had the "I just don't feel right" calls, and your assessment tells you something bad is going on.

My bad yall... :sad::sad:
 
EMSrush said:
Fair question. I'm still a new paramedic, and I was not lead on this call. I was a bit surprised at the feet dragging and "We're still working on his paperwork" delays that I encountered. I didn't feel like a had a tremendous amount of control over the call due to report already having been called in to the receiving ED, and not being the Pt's caregiver. I'm still trying to develop a balance between trusting my (limited but expanding) knowledge base, and the experience of others.

I ended this call feeling kind of "blah". I'm not even sure why, but I'm suspecting it has to do with my lack of participation and some confusion/uncertainty on my part. That's why I'm here.
Click to expand...

I get MI's too going from a hospital to a cath lab and people seem to be taking their good ol time with paperwork. Not sure what's up with that but its happens.
 
You can always count on the team here to set a person straight when you don't "paint the picture"------ the complete picture..
 
EMSRUSH

Reading 12-Leads are one of the most important things we do, you have to be an expert. Like I said, the monitors are not accurate, and a trained Paramedic is always better.

If you do not already know, research this stuff and look for it on future 12-leads.

Benign Early Repolarization
Left Ventricular Hypertrophy
Bundle Branch Blocks
Pericarditis

All of these can mimic elevation, but are not STEMIs!

As far as Bundle Branch Blocks and Paced Rythms, learn what the Sgcarbosa Criteria is so that you can read 12-leads and diagnose it even if the patient has a wide QRS, don't be one of those Medics who says I wont do a 12-Lead cause he is paced and you can't read a paced 12-lead, or look at it and say oh I see a LBBB can't interpret this 12-Lead now! 12-Leads really are fascinating and are very easy to read once you get the hang of it.

Like I said before, if ever you are on the bubble remember this. Is the elevation contiguos? Are there reciprical Changes?
 
MasterIntubator said:
Guess I should have worded it... "You will most likely know it", leaving it open for those uncommon ones.... as I too have had the "I just don't feel right" calls, and your assessment tells you something bad is going on.

My bad yall... :sad::sad:
Click to expand...

*Hand slap*
 
Fish said:
If you do not already know, research this stuff and look for it on future 12-leads.

Benign Early Repolarization
Left Ventricular Hypertrophy
Bundle Branch Blocks
Pericarditis

All of these can mimic elevation, but are not STEMIs!

As far as Bundle Branch Blocks and Paced Rythms, learn what the Sgcarbosa Criteria is so that you can read 12-leads and diagnose it even if the patient has a wide QRS, don't be one of those Medics who says I wont do a 12-Lead cause he is paced and you can't read a paced 12-lead, or look at it and say oh I see a LBBB can't interpret this 12-Lead now! 12-Leads really are fascinating and are very easy to read once you get the hang of it.

Like I said before, if ever you are on the bubble remember this. Is the elevation contiguos? Are there reciprical Changes?
Click to expand...

Thank you for your feedback. I really enjoy cardiology. What is concerning me is that I seem to have a fundamental difference of opinion with you guys about V4 (and I'm sure it's something relatively simple). Can someone please PM me and tell me what I'm missing? (or heck, flog me in public if you prefer...) The senior medic also felt there was elevation in V4... and V2. Not huge elevation, but still elevation.

I am well aware of some of the conditions that can mimic elevation. However, I'm not sure that it is good practice for me to pick and choose which ST elevations I treat as a confirmed STEMI and which I do not, with the exception of clear cut issues, such as a LBBB. It is, however, good information to keep in the back of your mind.

I agree with you on the contiguous leads, but NOT on reciprocal changes. There are not always reciprocal changes present, and reciprocal changes should not be relied upon when interpreting elevation.

Furthermore, I don't dx anything off a rhythm strip, other than... rhythm. A 12 lead always follows.
 
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